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Complaint Investigation Form <br /> Report#: 5104 <br /> 1 COMPLAINT ID: C00035277 Siie'L anon: 140E HARDING WAY ACCountlD: AR0001468 <br /> Received by: EE0090753 MARTINEZ <br /> Received Date: 8/2/2012 Print Date: <br /> Assigned To: EE0006293 PEDRAZA Ass8/2/2012 8:22:52AM <br /> Assigned Date: 8/2/2012 <br /> Program/Element Cade-1600-FOOD PROGRAM <br /> Complainant: : DOMINGA <br /> Address Nome Phone <br /> 480-380-9706 <br /> Work Phone <br /> Mail Address <br /> NaEDIARRHEA, <br /> e of com Taint: <br /> 7131 @ SPM SHE ATE EGG ROLLS,CHOW Mail ,.SWEET&SOUR PORK,CHICKEN INF IL.@ BQUT 6 PM SHE GOT SICK(VOMITING, i <br /> STOMACHACHEB DIZZINESS) -j �:'e4-4"41440 :1 <br /> Complaint Mode: p Complaint Mode Codes A-Agency Referral B-Bd of Supervisors l City-C 61 C-Counter F-Fax <br /> E-Code Enforcement M-Mai!f Correspondence O-Other EH Unit P-Phone <br /> I-Internet Email S-Sheriffs Office <br /> FACILITY INFORMATION T —OWNER INFORMATION ` <br /> Facility:FA0001469-GONGS RESTAURANT Owner: OW0001146-LEI,PAUL <br /> Sire Location 140 F HARDING WAY RP/DBA GONGS RESTAURANT <br /> STOCKTON,CA 95204 RP Address 5207 BARBADOS CT t <br /> Cross Street HARDING STOCKTON,CA 95210 k <br /> Mailing Address: 140 E HARDING WAY Billing Address 5207 BARBADOS CT <br /> STOCKTON,CA 95204 STOCKTON,CA 95210 <br /> Nome Phone <br /> Phone :209-464-0953 Work Phone <br /> District Location Code <br /> APN <br /> Dale Abated 2, / <br /> hT/ Inspector pe #: <br /> - - -- ----- ------- ---- — -- ---- ------- - -------- - - - <br /> Send <br /> ------ -------- —Send Referral to Referral Letter Sent by <br /> Referral Address Date: <br /> Complaint Status Code: t t <br /> Circle appropriate Status Code <br /> 12-DA Referred Complaint-See Violation Tracking Form <br /> 01-FIELD ABATED 15-ACTIVE HOUSING CASE-NEW COMPLAINT see ACTIVE CASE# <br /> 02-OFFICE ABATED 28-FOODBORNE ILLNESS-No Major Violations Identified <br /> 03-NAI SENT 29-FOODBORNE ILLNESS-Major Violations Identified <br /> 04-NOTICE TO ABATE ISSUED 50-LEAD Assessment Performed-No Abatement Required <br /> 05-DA-ENFORCEMENT ACTION INITIATED 52-LEAD Abatement Reqired-See Program Record File <br /> 06-EHD FACILITY-see Linked PROGRAM FACILITY FILE 97-Disaster Planning and Response <br /> 07-REFERRED TO OTHER AGENCY 99-UNSPECIFIED-Old Complaint-No Original Found <br /> 08-UNABLE TO VERIFY CL-Case Closed T <br /> 10-POSTED SUBSTANDARD/UNSECURED-See Housing File <br /> 11-Multiple Complaints-SEE ACTIVE CASE# <br /> 5104,rpt <br /> r <br />